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Client Statements of Rights:



Dakotah Consulting, Inc. Psychological Services is bound by the provisions of the Minnesota Privacy Act. No information will be released to persons or agencies outside of Dakotah Consulting, Inc. Psychological Services without your consent, except by court order.  If anyone inquires after information from Dakotah Consulting, Inc.  Psychological Services, related to you, or your record, your written permission is required.  Before granting permission, you must be satisfied that the information is really required.  Be sure that the information being given out and that giving it out will help you.  You may wish to refuse permission or withdraw it after it has been given.
When parents sign a permission form, minors may request that information in their file not be made available to their parents.  However, Dakotah Consulting, Inc. Psychological Services may not provide therapy services to minors without parental permission.


As a client or the Dakotah Consulting, Inc. / DCI Psychological Services, I have the following rights:

● To be treated with courtesy and respect.
● For staff to keep appointments as scheduled, or notify me of changes in case of an emergency.
● Staff will be free from intoxicating chemicals during professional contact.
● To be informed of expectations and responsibilities.
● To be an equal participant in treatment and care planning.
● Staff will comply with appropriate data practices and all privacy laws.
● Staff will keep information about myself and family confidential, only releasing such information upon my written consent, except as prescribed by low. 
● To have full and complete knowledge of the mental health provider’s qualifications and training.  
● Question the therapist’s competence and, if they so desire, to complain to the mental health provider’s 
supervisor or to file formal complaints with the appropriate professional or legal bodies that governs their proactive.  
● Request a copy of ethics codes and other guidelines and procedures that govern the mental health provider’s 
● Be informed fully regarding the terms under which any and all services will be provided to me or my family.  
● Discuss with the mental health provider, or other providers, the detailed explanation of any procedure or form 
of therapy that the provider recommends, prior to any treatment.  
● Request summaries, or at times direct access, of the clients own mental heath case file.  
● Refuse any and all evaluation or treatment of any kind unless the right of refusal is limited by law (as in instances of court-ordered evaluation or commitment).  
● Terminate therapy at any time or, in the case of court-ordered treatment, refuse to participate in the 
therapeutic process (recognizing that the client may have to face legal consequences as a result of their refusal).


As a client of the Dakotah Consulting, Inc. / DCI Psychological Services, I have the following responsibilities: 
● To keep appointment as scheduled, and to call in cases of an emergency.
● Treat staff with courtesy and respect.
● To be free from intoxicating chemicals during professional contact with all staff.
● Participate in case and treatment planning for myself and/or family members and follow through with the 
goals and tasks set forth in these plans.

I understand that the staff may raise concerns under the following situations: 
● Failure to comply with the responsibilities set forth above.
● Failure to complete case or treatment plan tasks or goals in the time frame established.
● Threatening or abusive behavior directed towards any staff.


The purpose of this statement is to insure that confidential information obtained regarding clients and / or their family members is kept secure and only released to outside parties when appropriately authorized in writing by the client, parent or guardian or according to state or federal laws requiring disclosure of confidential information.  Also, this statement is to establish a protocol for the secure storage of confidential client information.

1. All client records will be kept in a secure and locked facility.  The clinical staff that will have access to the record include the mental health professional providing services, the Clinical Director (or other licensed professional providing clinical supervision) and possibly a licensed mental health professional serving as a consultant to provide Q.I. / Q.A. services.

2. Confidential client data will be released only upon receipt of written consent by the client or the client's parent or guardian if a minor except in such cases covered by Minnesota laws wherein only a minor has authority to grant such consent which includes: minors who live apart from their parent / guardian and manage their own financial affairs, or who have been married or given birth to a child. Such authorizations must contain the following information:

The client's name and other identifying information such as date of birth,
Dakotah Consulting, Inc. / DCI Psychological Services name and address,
The name and address of who will receive the information,
What information, and only that information, that is to be released,
Why the information is being released (the purpose of the disclosure),
A notice that the consent can be revoked at any time and how long the consent will be valid.

3. Clients will also be informed of exceptions to confidentiality and cases where confidential information may be released without the client’s consent.  The following is a list of such instances:

A therapist receives information of an individual's intent to harm him or herself, someone else or to attempt suicide.  Actions in these circumstances may include arranging for hospitalization as well as notifying law enforcement authorities, family, friends and / or individuals who may be at risk (Terasoff Law). 

In the case of abuse and neglect of a child or vulnerable adult require our staff to report the situation to the appropriate authorities.

Clients who are pregnant and believed to be abusing drugs, state law requires this to be reported to appropriate authorities.

Minnesota law states that parents and spouses of deceased patients have the right of access to the deceased child or spouse's health record.

Minnesota law requires health-care professionals to report possible misconduct by another licensed health care professional in order for an investigation by the State Licensing Board.

A valid court order may require release of records or testimony.

In order to secure payment from my insurance company or other 3rd party insurance payor.


There may be times when the government may obtain information from our records.  Once the government has that information certain rules apply which prevent the government from releasing that information to anyone else, unless certain exceptions apply.

Disclosure of Government Health or Medical Data With Client Consent:

Unless one of the exceptions below applies, the government will not disclose information without your consent.  If you consent is requested, check the consent form for the following:

• The date. 
• Who the persons are that are going to disclose the data, the persons who will receive the information and the purpose for which the information may be used by the recipient. 
• The data to be disclosed.
• The expiration date which should not exceed one year (with certain exceptions).

Release of Government Health or Medical Data Without Your Consent:

The government may disclose health information without your consent:

• To your physician if it is necessary to diagnose, treat or identify persons who are at risk for certain 
illnesses or to conduct certain disease investigations (from the Center of Disease Control (CDC)).
• As necessary to prepare summary or “sanitized” data to another government official authorized or 
required access by federal or state law (i.e. just identifying information only, like birthdates, etc.). 
• To the nearest surviving member of a deceased client’s family, unless the client directs otherwise, to 
communicate the client’s condition to the survivor according to an “accepted medical practice” (i.e. living will). 
• To administer federal funds for programs.
• Pursuant to a valid court order or as otherwise required by law.


Transportation Policies:

● All passengers are required to wear seatbelts by law.  Infants and young children will use car seats according to state law 
● Due to passenger side airbags, no child under the age of twelve years old, under 100 pounds and / or under 5 
feet will be allowed to sit in the front passenger seat.
● Keys to the vehicle as well as other keys must be kept in the possession of staff at all times.  Keys must never 
be accessible or left in the possession of clients.
● Staff using their own vehicles for program business must submit proof of insurance.
● Clients must assist in the safe operation of the vehicle by sitting quietly and remaining in his / her seat.  No 
disruptive behavior will be tolerated. 
● All clients will be notified of the rules and expectations of the transportation policies.

Youth and Family Services & Activities: 

● All family services and activities require parents to be responsible for their children at all times.  During 
services when parents are not present; staff is responsible for supervision of youth. 
● All staff working directly with clients will submit to a criminal background check. 
● Clients will be notified if activities and meetings are canceled due to severe weather (within an appropriate 
time frame).

Client Conduct and Safety Procedures:

For privacy reasons, all appointments that occur at Dakotah Consulting, Inc. / DCI Psychological Services will occur in spaces that have been reserved for use.  Smoking is restricted to the outside of the building.  Smokers must be 18 years of age or older.

Alcohol or drug use is not permitted in the building in general.  If participants are suspected to be under the influence they will be asked to leave and may jeopardize their involvement with the services.

Any verbal or physical threats are prohibited.  Anyone using racial or sexual slurs, or found to be acting physically or verbally threatening will be excluded from services & other activities, until staff has resolved the situation and feels confident that inappropriate behavior will not continue in the future.


I have received the following Information:

● Client Rights & Responsibilities
● Minnesota Data Practices Act
● Confidentiality Statement
● Miscellaneous policies

I have had the opportunity to read and review these policies and address any questions or concerns about them and / or the information contained in them with my therapist or other mental health professional.  I certify that I understand my rights as a recipient of psychological and / or other clinical services, my responsibilities as a client of the Dakotah Consulting, Inc. / DCI Psychological Services and my rights as a subject of data.  I am aware of the limits to confidentiality regarding information about myself, child, family member or other person under my care and my therapist has explained to me the exceptions to such confidentiality.

I give permission to the Dakotah Consulting, Inc. / DCI Psychological Services to provide psychological, or other clinical services to myself, child, or other person for whom I am responsible.

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